# Chapter 25 My Nursing Test Banks

DAmico/Barbarito Health & Physical Assessment in Nursing, 2/e
Chapter 25

Question 1

Type: MCSA

The nurse is performing an assessment on a 13-yearold adolescent. Which of the following findings would be unexpected?

1. Apical heart rate of 110 beats per minute

2. Respiratory rate of 14 breaths per minute

3. Blood pressure of 98/58

4. Temperature of 98.8 degrees Fahrenheit

Rationale 1: A 13-year-old adolescents heart rate normally ranges from 65 to 120 beats per minute.

Rationale 2: A 13-year-old adolescents respiratory rate normally ranges from 14 to 20 breaths per minute.

Rationale 3: A 13-year-old adolescents blood pressure usually ranges from 110 to 131 mm Hg (systolically), and 64 to 84 mm Hg (diastolically).

Rationale 4: The 13-year-old adolescents temperature is within normal limits.

Global Rationale: A 13-year-old adolescents blood pressure usually ranges from 110 to 131 mm Hg (systolically), and 64 to 84 mm Hg (diastolically). This 13-year-old adolescents blood pressure is low. A 13-year-old adolescents heart rate normally ranges from 65 to 120 beats per minute. A 13-year-old adolescents respiratory rate normally ranges from 14 to 20 breaths per minute. The 13-year-old adolescents temperature is within normal limits.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 25.1: Identify anatomical differences between children and adults.

Question 2

Type: MCSA

The nurse is performing an assessment of a 7 month old. Which of the following findings may be unexpected?

1. The anterior fontanelle is closed.

2. The posterior fontanelle is closed.

3. The head is disproportionately large in comparison to the body.

4. There are two baby teeth present.

Rationale 1: The anterior fontanelle usually closes when the infant is between 9 and 18 months of age. It is an unexpected finding to determine the infants anterior fontanelle is already closed at the age of 7 months.

Rationale 2: The posterior fontanelle usually closes by the age of 2 months.

Rationale 3: The head remains disproportionately large in comparison to the body until approximately 5 years of age.

Rationale 4: The child should have at least one tooth present in the mouth by 15 months of age.

Global Rationale: The anterior fontanelle usually closes when the infant is between 9 and 18 months of age. It is an unexpected finding to determine the infants anterior fontanelle is already closed at the age of 7 months. The posterior fontanelle usually closes by the age of 2 months. The head remains disproportionately large in comparison to the body until approximately 5 years of age. The child should have at least one tooth present in the mouth by 15 months of age.

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 25.1: Identify anatomical differences between children and adults.

Question 3

Type: MCSA

The nurse is assessing a newborn when the mother asks about the tiny white bumps on the forehead and nose. The nurse would respond to the mother with which of the following statements?

1. Those are milia and they are very common.

2. That is lanugo and it is very common.

3. Those are Mongolian spots.

4. Those are salmon patches.

Rationale 1: Milia are tiny (less than 0.5 mm), smooth, white cysts of the hair follicle found commonly on the forehead and nose at birth.

Rationale 2: Lanugo is a covering of fine hair in newborns found on the upper chest, shoulders, and back.

Rationale 3: Mongolian spots are areas of dark bluish pigmentation and are most commonly found at the base of the spine.

Rationale 4: Salmon patches, also known as stork bites, are small macules and patches caused by visible intradermal capillaries and are found on the forehead, eyelids, upper lip, nasal bridge, and nape of the neck.

Global Rationale: Milia are very small (less than 0.5 mm), smooth, white cysts of the hair follicle found commonly on the forehead and nose at birth. Milia are normal infant variations. Lanugo is a covering of fine hair in newborns found on the upper chest, shoulders, and back. Mongolian spots are areas of dark bluish pigmentation and are most commonly found at the base of the spine. Salmon patches, also known as stork bites, are small macules and patches caused by visible intradermal capillaries and are found on the forehead, eyelids, upper lip, nasal bridge, and nape of the neck.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 25.1: Identify anatomical differences between children and adults.

Question 4

Type: MCSA

The nurse is preparing to perform an assessment on four children. After reviewing each childs admitting diagnosis, which of the following children may have an enlarged spleen?

1. 14 year old admitted with acute gastroenteritis

2. 17 year old admitted with an acute exacerbation of asthma

3. 11 year old admitted with an umbilical hernia

4. 9 year old admitted with a sickle cell crisis

Rationale 1: It would be unlikely that the 14 year old with acute gastroenteritis would exhibit splenomegaly (enlarged spleen).

Rationale 2: It would be unlikely that the 17 year old with an acute exacerbation of asthma would exhibit splenomegaly (enlarged spleen).

Rationale 3: It would be unlikely that the 11 year old with an umbilical hernia would exhibit splenomegaly (enlarged spleen).

Rationale 4: Splenomegaly is common in young children with sickle cell disease (SCD). All children with SCD should be assessed for splenomegaly (enlarged spleen).

Global Rationale: Splenomegaly (enlarged spleen) is common in young children with sickle cell disease (SCD). All children with SCD should be assessed for splenomegaly. It would be unlikely that the 14 year old with acute gastroenteritis would exhibit splenomegaly. It would be unlikely that the 17 year old with an acute exacerbation of asthma would exhibit splenomegaly. It would be unlikely that the 11 year old with an umbilical hernia would exhibit splenomegaly.

Cognitive Level: Remembering

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 25.1: Identify anatomical differences between children and adults.

Question 5

Type: MCSA

The parents of a 3-year-old child with a history of frequent otitis media incidences ask the nurse why their child continues to have this issue. Which of the following is the nurses best response?

1. Children of this age frequently put things in their ears.

2. The eustachian tubes are shorter, more level, and straighter in children this age.

3. Children of this age experience more difficulty washing their hands appropriately.

4. The child has a hearing problem that is causing this to occur more frequently.

Rationale 1: Putting objects in the ear is possible, but not necessarily typical of children of this age.

Rationale 2: Children under 4 years of age are more prone to develop otitis media. The eustachian tubes of young children are shorter, straighter, and more level than in older children.

Rationale 3: Children of this age probably do experience more difficulty washing their hands appropriately. However, the best response for the parents is to discuss the anatomical differences in their young childs ears that make the child more likely to develop otitis media.

Rationale 4: A hearing problem would not cause the otitis media, but frequent ear infections may result in a hearing problem.

Global Rationale: Children under 4 years of age are more prone to develop otitis media. The eustachian tubes of young children are shorter, straighter, and more level than in older children. Putting objects in the ear is possible, but not necessarily typical of children of this age. Children of this age probably do experience more difficulty washing their hands appropriately. However, the best response for the parents is to discuss the anatomical differences in their young childs ears that make the child more likely to develop otitis media. A hearing problem would not cause the otitis media, but frequent ear infections may result in a hearing problem.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 25.1: Identify anatomical differences between children and adults.

Question 6

Type: MCMA

The mother of a 17-year-old female has brought her daughter in for an examination. Which of the following statements by the client is most consistent with the clients most likely diagnosis?

Standard Text: Select all that apply.

1. I usually just feel so tired.

2. Ive been growing this strange, soft, light-colored fur all over.

3. Everyone says Im thin, but I dont feel like I look thin.

4. I perspire all of the time and my skin is so oily.

5. Im sorry, but I cannot get warm. Can you turn up the heat in this place?

Rationale 1: I usually just feel so tired. This young lady is most likely suffering from anorexia nervosa. It is common for clients who are suffering from anorexia nervosa to complain of feeling weak and tired.

Rationale 2: Ive been growing this strange, soft, light-colored fur all over. Lanugo is a soft white hair growth on the client with anorexia nervosa.

Rationale 3: Everyone says Im thin, but I dont feel like I look thin. Clients with anorexia nervosa commonly feel that they are not underweight, although they are exceedingly thin.

Rationale 4: I perspire all of the time and my skin is so oily. Clients with anorexia nervosa more commonly complain of dry skin, not excessive perspiration and oily skin.

Rationale 5: Im sorry, but I cannot get warm. Can you turn up the heat in this place? The client with anorexia nervosa often suffers from cold intolerance.

Global Rationale: This young lady is most likely suffering from anorexia nervosa. It is common for clients who are suffering from anorexia nervosa to complain of feeling weak and tired. Lanugo is a soft white hair growth on the client with anorexia nervosa. Clients with anorexia nervosa commonly feel that they are not thin, although they are exceedingly thin. Clients with anorexia nervosa more commonly complain of dry skin, not excessive perspiration. The client with anorexia nervosa often suffers from cold intolerance.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 25.2: Perform an age-appropriate history and physical assessment of a child.

Question 7

Type: MCMA

The child has been diagnosed with acute otitis media. Which of the following findings by the nurse are consistent with this diagnosis?

Standard Text: Select all that apply.

1. Temperature is 101.4 degrees Fahrenheit.

2. The tympanic membrane is pearly gray.

3. The mother states, I cannot get her to eat anything. She just picks at her food.

4. The mother states, She has been so fussy.

5. The mother states, She can sleep only while shes sitting up on my lap while Im in the rocking chair.

Rationale 1: Temperature is 101.4 degrees Fahrenheit. This child has a fever, which is consistent with acute otitis media.

Rationale 2: The tympanic membrane is pearly gray. The tympanic membrane of a child with acute otitis media will be orange-red or red and bulging with purulent drainage within the middle ear space. A pearly gray tympanic membrane is a normal finding.

Rationale 3: The mother states, I cannot get her to eat anything. She just picks at her food. The child is anorexic and not eating well currently. This is consistent with acute otitis media.

Rationale 4: The mother states, She has been so fussy. Irritability is associated with acute otitis media.

Rationale 5: The mother states, She can sleep only while shes sitting up on my lap while Im in the rocking chair. Children with acute otitis media may not be able to sleep while lying down.

Global Rationale: This child has a fever, which is consistent with acute otitis media. The child is anorexic and not eating well currently. This is consistent with acute otitis media. Irritability is associated with acute otitis media. Children with acute otitis media may not be able to sleep while lying down. The tympanic membrane of a child with acute otitis media will be orange-red or red and bulging with purulent drainage within the middle ear space. A pearly gray tympanic membrane is a normal finding.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 25.2: Perform an age-appropriate history and physical assessment of a child.

Question 8

Type: FIB

The child has been admitted to the Intensive Care Unit following a motor vehicle accident. The child weighs 39 pounds. Calculate the childs minimum expected urinary output in milliliters over an 8-hour period. Round to the nearest whole number.
__________ milliliters

Standard Text:

Rationale: Normal urine output for children is at least 1 ml/kg/hr. The child weighs 39 pounds. To calculate the childs weight in kilograms, 39 pounds is divided by 2.2. There are 2.2 pounds in each kilogram. The child should produce at least 1 milliliter per kilogram each hour. The child weighs 17.727 kilograms. Multiply this number by 1 milliliter/kilogram. This is 17.727 milliliters of urine produced each hour. Multiply this number by 8, and it equals 141.818. When rounded to a whole number, this is 142 milliliters.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 25.2: Perform an age-appropriate history and physical assessment of a child.

Question 9

Type: MCMA

An 18-month-old child is brought to the emergency room with difficulty breathing. The physician diagnoses the child with epiglottitis. Which of the following findings by the nurse are consistent with this diagnosis?

Standard Text: Select all that apply.

1. Oxygen saturation level is 85% on room air.

2. Respiratory rate is 22 per minute.

3. Stridor is audible without stethoscope.

4. Apical heart rate is 72 beats per minute.

5. Temperature is 103.7 degrees Fahrenheit.

Rationale 1: Oxygen saturation level is 85% on room air. The child with epiglottitis may have a decreased oxygen saturation level. 85% is lower than normal.

Rationale 2: Respiratory rate is 22 per minute. The respiratory rate is normal for a child between 1 and 2 years old. The child with epiglottitis will more likely exhibit an increased respiratory rate.

Rationale 3: Stridor is audible without stethoscope. Audible stridor is associated with epiglottitis.

Rationale 4: Apical heart rate is 72 beats per minute. The childs heart rate is within normal limits for the childs age.

Rationale 5: Temperature is 103.7 degrees Fahrenheit. The child has a high fever and this is associated with epiglottitis.

Global Rationale: The child with epiglottitis may have a decreased oxygen saturation level. 85% is lower than normal. The child with epiglottitis will more likely exhibit an increased respiratory rate. Audible stridor is associated with epiglottitis. The child has a high fever and this is associated with epiglottitis. The respiratory rate is normal for a child between 1 and 2 years old. The childs heart rate is within normal limits for the childs age.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 25.2: Perform an age-appropriate history and physical assessment of a child;

Question 10

Type: MCSA

The nurse is assessing the newborn and notes the presence of a bluish discoloration of the hands and feet. Which of the following actions would be most important for the nurse to perform next?

1. Assess the oral mucosa.

2. Obtain the newborns temperature.

3. Apply a blanket.

4. Assess capillary refill.

Rationale 1: Acrocyanosis is the bluish discoloration of the hands and feet. It is a common finding in newborns and infants during times of stress and exposure to cold environments. The nurse must differentiate this benign finding from true cyanosis by examining the oral mucosa.

Rationale 2: The newborn may be suffering from hypothermia, but the nurse should first determine if the newborn is experiencing true cyanosis or acrocyanosis.

Rationale 3: Applying a blanket is important, but the nurse must first determine if the newborn is experiencing true cyanosis or acrocyanosis.

Rationale 4: Capillary refill is important to assess, but the most important thing to do at this point, is to determine if the newborn is experiencing true cyanosis or acrocyanosis.

Global Rationale: Acrocyanosis is the bluish discoloration of the hands and feet. It is a common finding in newborns and infants during times of stress and exposure to cold environments. The nurse must differentiate this benign finding from true cyanosis by examining the oral mucosa. In true cyanosis, the oral mucosa, lips, and tongue will also be cyanotic. The newborn may be suffering from hypothermia, but the nurse should first determine if the newborn is experiencing true cyanosis or acrocyanosis. Applying a blanket is important, but the nurse must first determine if the newborn is experiencing true cyanosis or acrocyanosis. Capillary refill is important to assess, but the most important thing to do at this point is to determine if the newborn is experiencing true cyanosis or acrocyanosis.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 25.2: Perform an age-appropriate history and physical assessment of a child.

Question 11

Type: MCSA

The nurse has assessed a 7-year-old female. The child has a moderate amount of pubic and axillary hair. The mother states, I just think she is going through puberty early. I was 11 when I went through these changes. The nurses best response would be:

1. Your daughter is very young to be experiencing these types of changes.

2. You are probably right, since you went through these types of changes early.

3. This type of hair growth is normally associated with cardiovascular disorders.

4. Are her friends experiencing the same changes?

Rationale 1: The presence of pubic, facial, or axillary hair in a prepubescent child is indicative of endocrinologic disease.

Rationale 2: The nurse should not give any diagnosis, but alert the mother that this is not a normal finding in a child of this age.

Rationale 3: The presence of pubic, facial, or axillary hair in a prepubescent child is indicative of endocrinologic disease.

Rationale 4: Whether or not her friends are experiencing the same changes does not address this specific childs issues.

Global Rationale: The nurse should not give any diagnosis, but alert the mother that this is not a normal finding in a child of this age. The mother was not necessarily early to begin changes at 11 years of age. The presence of pubic, facial, or axillary hair in a prepubescent child is indicative of endocrinologic disease. Whether or not her friends are experiencing the same changes does not address this specific childs issues.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 25.2: Perform an age-appropriate history and physical assessment of a child.

Question 12

Type: FIB

The 5-year-old childs mother asks how much her childs bladder can hold. She states, It seems like if we visit my mother who lives 2 hours away, we always have to stop once so that my child can pee. I just wondered how big his bladder may be. Calculate the maximum amount of urine that the child can hold within the bladder in milliliters.

________ milliliters

Standard Text:

Rationale: To calculate this number, use the following equation: Age in years + 2 oz = 5 + 2 oz= 7 oz. There are 30 milliliters in every ounce. 7 oz times 30 milliliters is 210 milliliters.

Global Rationale:

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 25.2: Perform an age-appropriate history and physical assessment of a child.

Question 13

Type: MCSA

The mother of a 7-year-old child states, Im concerned because I can feel a few lumps at the base of his neck. The nurse notes slightly enlarged, firm, nontender, cervical lymph nodes. The lymph nodes are easily moveable under the skin. Which of the following interventions would be appropriate?

1. Speak with the physician about acquiring a throat culture.

2. Assess the clients temperature.

3. Examine the childs tonsils for tonsillitis.

4. Explain to the mother that this is a normal finding.

Rationale 1: The client is not exhibiting any clinical manifestations associated with pharyngitis, so a throat culture is not warranted.

Rationale 2: The client is not exhibiting any clinical manifestations of an infection that would result in hyperthermia.

Rationale 3: The client is not exhibiting any clinical manifestations of tonsillitis.

Rationale 4: Shotty lymph nodes are a normal variant in preschool and school-age children, and are noninfected, nontender, enlarged nodes that move when palpated.

Global Rationale: Shotty lymph nodes are a normal variant in preschool and school-age children, and are noninfected, nontender, enlarged nodes that move when palpated. The client is not exhibiting any clinical manifestations associated with pharyngitis, so a throat culture is not warranted. The client is not exhibiting any clinical manifestations of an infection that would result in hyperthermia. The client is not exhibiting any clinical manifestations of tonsillitis.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 25.2: Perform an age-appropriate history and physical assessment of a child.

Question 14

Type: MCSA

The nurse is interviewing the mother of a 6 month old during a well-child visit. The mother reports that there is a watery drainage from the infants left eye with some crusting present within the eyelashes. The nurse inspects the infants left eye and agrees with the mothers assessment. In which of the following ways would the nurse accurately document this finding?

1. Exotropia

2. Esotropia

3. Dacryostenosis

4. Congenital cataracts

Rationale 1: Exotropia causes the covered eye to move outward (laterally).

Rationale 2: Esotropia causes the covered eye to move inward (medially).

Rationale 3: Dacryostenosis is the congenital blockage of the tear ducts and is a normal variant until 9 months of age. The infant with dacryostenosis will present with unilateral tearing and non-purulent crusting.

Rationale 4: Congenital cataracts cause the cornea to appear hazy or cloudy.

Global Rationale: Dacryostenosis is the congenital blockage of the tear ducts and is a normal variant until 9 months of age. The infant with dacryostenosis will present with unilateral tearing and nonpurulent crusting. Exotropia causes the covered eye to move outward (laterally). Esotropia causes the covered eye to move inward (medially). Congenital cataracts cause the cornea to appear hazy or cloudy.

Cognitive Level: Remembering

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 25.2: Perform an age-appropriate history and physical assessment of a child.

Question 15

Type: MCSA

The nurse is assessing a newborn and abducts the hips and palpates the greater and lesser trochanter while flexing the hips and knees at a 90-degree angle. The nurse is assessing which of the following?

1. Barlows maneuver

2. Knee fracture

3. Galeazzi sign

4. Ortolanis maneuver

Rationale 1: Barlows maneuver. Barlows maneuver is also used to assess for hip dysplasia. The nurse utilizes the same hand palpation position while the nurse adducts the hip while gently lifting the thigh and placing pressure on the trochanter.

Rationale 2: Knee fracture. This assessment is not performed specifically to assess for knee fractures.

Rationale 3: Galeazzi sign. Galeazzi sign is positive when the infant has differing knee heights.

Rationale 4: Ortolanis maneuver. The procedure described is called Ortolanis maneuver and is used to assess dysplasia of the hip.

Global Rationale: The procedure described is called Ortolanis maneuver and is used to assess dysplasia of the hip. Barlows maneuver, which also assesses hip dysplasia, utilizes the same hand palpation position while the nurse adducts the hip while gently lifting the thigh and placing pressure on the trochanter. This assessment is not performed specifically to assess for knee fractures. Galeazzi sign is positive when the infant has differing knee heights.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 25.2: Perform an age-appropriate history and physical assessment of a child.

Question 16

Type: MCMA

The nurse is performing an otoscopic examination in a child and notes the child expressing pain as the pinna is manipulated to better examine the tympanic membrane. Which of the following findings is consistent with the most likely condition?

Standard Text: Select all that apply.

1. Erythema is noted along the childs ear canal.

2. The tympanic membrane is in a full position, amber-colored, and immobile.

3. The external ear is abnormally protruding forward.

4. Edema is noted within the childs ear canal.

5. Light yellow drainage is noted within the ear canal.

Rationale 1: Erythema is noted along the childs ear canal. Otitis externa results a reddened ear canal.

Rationale 2: The tympanic membrane is in a full position, amber-colored, and immobile.Otitis media with effusion appears with non-purulent fluid in the middle ear space, causing edema in the eustachian tubes.

Rationale 3: The external ear is abnormally protruding forward. Mastoiditis causes the childs external ear to protrude forward.

Rationale 4: Edema is noted within the childs ear canal. Otitis externa results in edema within the ear canal.

Rationale 5: Light yellow drainage is noted within the ear canal. Purulent drainage from the ear canal can indicate that the child has developed otitis externa.

Global Rationale: Otitis externa results in pain with pinna manipulation and red, edematous ear canals with or without purulent discharge. Otitis media with effusion appears with nonpurulent fluid in the middle ear space, causing edema in the eustachian tubes. Mastoiditis causes the childs external ear to protrude forward.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 25.2: Perform an age-appropriate history and physical assessment of a child.

Question 17

Type: MCSA

The nurse needs to assess the young childs gait and range of motion of the extremities. Which of the following instructions is a commonly used method during this portion of the childs assessment?

1. I need you to pretend to be a duck. Squat and move forward while flapping your arms.

2. Let me see you jump in place on both feet.

3. Please hop across the room on one foot and then come back by hopping on the other foot.

4. Would you please do some jumping jacks for me?

Rationale 1: The duck walk involves squatting and moving forward while flapping the upper arms and can be used to evaluate normal range of motion, muscle strength, and coordination in a child.

Rationale 2: Jumping in place on both feet will not provide information about range of motion of all of the childs extremities.

Rationale 3: Hopping on one foot and then the other across a room will not provide information about range of motion.

Rationale 4: Jumping jacks may be difficult for some young children to perform due to lack of coordination and is not a commonly used method for assessing gait and range of motion of the extremities.

Global Rationale: The duck walk involves squatting and moving forward while flapping the upper arms and can be used to evaluate normal range of motion, muscle strength, and coordination in a child. Jumping in place on both feet will not provide information about range of motion of all of the childs extremities. Hopping on one foot and then the other across a room will not provide information about range of motion. Jumping jacks may be difficult for some young children to perform due to lack of coordination and is not a commonly used method for assessing gait and range of motion of the extremities.

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 25.2: Perform an age-appropriate history and physical assessment of a child.

Question 18

Type: MCSA

The nurse is examining a child. The childs pharynx is reddened, with yellow exudate noted on each tonsil. The tongue is red with enlarged taste buds. Petechiae are visualized on the childs soft palate near the uvula. Which of the following physician orders is most important and appropriate for this child?

1. Saline mouth rinses

2. Throat culture

3. Dental referral

4. Aspirin for pain

Rationale 1: Saline mouth rinses may help with the clients discomfort but is not the most important intervention. This child needs to be started on the appropriate antibiotic if the child has strep throat.

Rationale 2: Strep throat infection, caused by group A beta-hemolytic Streptococcus pyogenes, may cause yellow tonsillar exudates, erythematous and edematous pharynx, red tongue with prominent taste buds (strawberry tongue), and petechial hemorrhages on the soft palate near the uvula.

Rationale 3: A dental referral is inappropriate. This child needs to be started on the appropriate antibiotic if the child has strep throat.

Rationale 4: Aspirin for pain is inappropriate because it can result in Reyes syndrome when taken by children.

Global Rationale: Strep throat infection, caused by group A beta-hemolytic Streptococcus pyogenes, may cause yellow tonsillar exudates, erythematous and edematous pharynx, red tongue with prominent taste buds (strawberry tongue), and petechial hemorrhages on the soft palate near the uvula. Saline mouth rinses may help with the clients discomfort but is not the most important intervention. A dental referral is inappropriate. This child needs to be started on the appropriate antibiotic if the child has strep throat. Aspirin for pain is inappropriate because it can result in Reyes syndrome when taken by children.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 25.2: Perform an age-appropriate history and physical assessment of a child.

Question 19

Type: MCSA

The nurse is assessing a newborn and notes that the infant has six fingers on the left hand. The nurse would accurately document this information in which of the following ways?

1. Syndactyly

2. Polydactyly

3. Brachial plexus injury

4. Erbs palsy

Rationale 1: Syndactyly is a term used to describe the presence of webbed fingers.

Rationale 2: Polydactyly is the presence of extra fingers.

Rationale 3: Entire brachial plexus palsy results in no movement of the shoulder, arm, and hand. Unfortunately, this type of brachial plexus injury has a poor prognosis.

Rationale 4: Erbs palsy is one type of brachial plexus injury. It is a transient condition that results in paralysis of the shoulder and upper arm.

Global Rationale: Polydactyly is the presence of extra fingers. Syndactyly is a term used to describe the presence of webbed fingers. A brachial plexus injury results in paralysis of the shoulder and upper arm from birth trauma. Entire brachial plexus palsy results in no movement of the shoulder, arm, and hand. Unfortunately, this type of brachial plexus injury has a poor prognosis. Erbs palsy is one type of brachial plexus injury. It is a transient condition that results in paralysis of the shoulder and upper arm.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 25.2: Perform an age-appropriate history and physical assessment of a child.

Question 20

Type: MCSA

The nurse is assessing the child and notes that there is a depression in the lower part of the sternum. The nurse would accurately document this finding in which of the following ways?

1. Normal sternal border

2. Pectus carinatum

3. Barrel chest

4. Pectus excavatum

Rationale 1: A normal sternum does not contain these types of depressions or bowing.

Rationale 2: Pectus carinatum is also called pigeon chest. It is associated with a bowing of the sternum.

Rationale 3: Barrel chest, or an increased anterioposterior chest diameter, is normally seen in infancy, or with chronic respiratory disorders and normal aging.

Rationale 4: Pectus excavatum is also called funnel chest. It is associated with a depression in the lower part of the sternum.

Global Rationale: Pectus excavatum is also called funnel chest. It is associated with a depression in the lower part of the sternum. A normal sternum does not contain these types of depressions or bowing. Pectus carinatum is also called pigeon chest. It is associated with a bowing of the sternum. Barrel chest, or an increased anterioposterior chest diameter, is normally seen in infancy, or with chronic respiratory disorders and normal aging.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 25.2: Perform an age-appropriate history and physical assessment of a child.

Question 21

Type: FIB

The nurse is educating the childs parents about the importance of limiting the childs intake of fruit juice to less than 12 ounces each day. Calculate the number of ounces the child has had during the last 24 hours.
120 milliliters of orange juice, 60 milliliters of grape juice, 90 milliliters of cranberry-grape juice _____ ounces

Standard Text:

Rationale: There are 30 milliliters in 1 ounce. The child drank 270 milliliters of fruit juice during the last 24 hours. 270 milliliters divided by 30 milliliters/ ounce = 9 ounces.

Global Rationale:

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 25.2: Perform an age-appropriate history and physical assessment of a child.

Question 22

Type: MCSA

The nurse is performing an otoscopic examination of a 3-year-old child. As the nurse prepares to examine the clients tympanic membrane with the ototscope, the nurse would correctly choose which of the following techniques?

1. Pull the tragus up and back while inserting the otoscope.

2. Pull the ear lobe up and back while inserting the otoscope.

3. Pull the ear lobe down and back while inserting the otoscope.

4. Pull the tragus down and back while inserting the otoscope.

Rationale 1: The tragus should be manipulated up and back when examining an older childs tympanic membrane.

Rationale 2: The tragus, not the ear lobe, should be manipulated up and back when examining an older childs tympanic membrane.

Rationale 3: The nurse should not manipulate the childs ear lobe while inserting the otoscope. It would be more helpful to pull the childs tragus down and back to insert the otoscope correctly.

Rationale 4: In children under the age of 4 years, the tragus should be pulled down and back while the otoscope is inserted. This allows for the speculum to follow the curve of the auditory canal.

Global Rationale: In children under the age of 4, the tragus should be pulled down and back while the otoscope is inserted. This allows for the speculum to follow the curve of the auditory canal. Manipulating the ear lobe will be less helpful to the nurse who wishes to examine the childs ear. The tragus, not the ear lobe, should be manipulated up and back when examining an older childs tympanic membrane.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 25.3: Use techniques that foster child compliance and safety during physical assessment.

Question 23

Type: MCSA

The nurse determines that nutritional education is needed for the family of an 8 month old after the history reveals the following: the infant is drinking whole milk 3 times a day from a bottle, eats table food such as hot dogs and grapes with the 2-year-old sibling, and is allowed gum as a reward for good behavior. Which part of the data would the nurse be able to support as being correct for a child of this age?

1. Consumption of whole milk

2. Eating table foods such as hot dogs and grapes

3. Has been given gum for good behavior

4. Drinking from a bottle

Rationale 1: An infant of this age should be consuming commercial, iron-fortified formula or breast milk. Whole milk is introduced, usually in a cup, at 1 year of age.

Rationale 2: The child should not be consuming hot dogs or grapes, as both are choking hazards. These types of foods could produce choking in the 2-year-old sibling as well, and would not be recommended.

Rationale 3: Rewarding an 8-month-old infant for good behavior with a choking hazard such as gum is inappropriate.

Rationale 4: The best information reported about this childs nutritional consumption is that the infant continues to drink from a bottle. It is unlikely that a child of this age would be able to drink effectively from a cup.

Global Rationale: The best information reported about this childs nutritional consumption is that the infant continues to drink from a bottle. It is unlikely that a child of this age would be able to drink effectively from a cup. An infant of this age should be consuming commercial, iron-fortified formula or breast milk. Whole milk is introduced, usually in a cup, at 1 year of age. The child should not be consuming hot dogs or grapes, as both are choking hazards, even for the 2-year-old sibling. Rewarding an 8-month-old infant for good behavior with a choking hazard such as gum is inappropriate.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 25.4: Incorporate the physical, cognitive, and emotional development of children into comprehensive health assessment.

Question 24

Type: MCMA

The student nurse is preparing to perform an assessment on a 5-year-old Arab American child with a possible case of otitis media. The experienced nurse accompanies the student nurse. Which of the following statements by the student nurse indicate that further education is required?

Standard Text: Select all that apply.

1. It would be best to have the child sit in his moms lap if we have to give him a shot.

2. Before I listen to the childs lungs, I can let him play with my stethoscope.

3. I will be able to see the tympanic membrane more clearly if I pull the tragus down and back.

4. It really doesnt matter what his culture is; mommies always make the decisions about childrens health care issues.

5. Im going to have to be firm but friendly with my approach to the child.

Rationale 1: It would be best to have the child sit in his moms lap if we have to give him a shot. Painful procedures should not be performed while a child is seated on a parents lap. Children need to know they are safe from painful experiences when they are with their parents.

Rationale 2: Before I listen to the childs lungs, I can let him play with my stethoscope. Whenever possible, play should be incorporated into nursing procedures. It is helpful to allow children to touch and manipulate equipment.

Rationale 3: I will be able to see the tympanic membrane more clearly if I pull the tragus down and back. The student nurse should pull the pinna up and back because the child is older than 4 years of age.

Rationale 4: It really doesnt matter what his culture is; mommies always make the decisions about childrens health care issues. Arab Americans have patriarchal hierarchies where the father must be consulted prior to any professional healthcare decisions.

Rationale 5: Im going to have to be firm but friendly with my approach to the child. Nurses should use a caring, supportive, yet firm approach with children.

Global Rationale: Painful procedures should not be performed while a child is seated on a parents lap. Children need to know they are safe from painful experiences when they are with their parents. The student nurse should pull the pinna up and back because the child is older than 4 years of age. Arab Americans have patriarchal hierarchies where the father must be consulted prior to any professional healthcare decisions. Whenever possible, play should be incorporated into nursing procedures. It is helpful to allow children to touch and manipulate equipment. Nurses should use a caring, supportive, yet firm approach with children.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 25.4: Incorporate the physical, cognitive, and emotional development of children into comprehensive health assessment.

Question 25

Type: MCMA

The nurse is performing an assessment on the following 5 newborns. Which of the newborns does the nurse expect to exhibit Mongolian spots?

Standard Text: Select all that apply.

1. African American newborn

2. Caucasian newborn

3. Hispanic newborn

4. Native American newborn

5. Asian newborn

Rationale 1: African American newborn. African American newborns commonly exhibit Mongolian spots.

Rationale 2: Caucasian newborn. The Caucasian newborn does not commonly exhibit Mongolian spots.

Rationale 3: Hispanic newborn. The Hispanic newborn commonly exhibits Mongolian spots.

Rationale 4: Native American newborn. The Native American newborn commonly exhibits Mongolian spots.

Rationale 5: Asian newborn. The Asian newborn commonly exhibits Mongolian spots.

Global Rationale: African American newborns commonly exhibit Mongolian spots. The Hispanic newborn commonly exhibits Mongolian spots. The Native American newborn commonly exhibits Mongolian spots. The Asian newborn commonly exhibits Mongolian spots. The Caucasian newborn does not commonly exhibit Mongolian spots.

Cognitive Level: Remembering

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 25.4: Incorporate the physical, cognitive, and emotional development of children into comprehensive health assessment.

Question 26

Type: MCSA

The student nurse is preparing to provide care for several newborns and their families. The experienced nurse is present to ensure appropriate care is provided. Which of the following statements by the student nurse indicates that further education is required?

1. The newborns parents recently moved here from Mexico, so we need to ensure that the baby is tested for sickle cell anemia.

2. When dealing with the Chinese parents, it is important to remember that they may not make a lot of direct eye contact when Im talking with them.

3. When dealing with the parents from Mexico, I must make sure that I do not touch the baby when I compliment him.

4. The babys parents were raised on the Indian reservation. We should make sure the baby is tested for hypothyroidism.

Rationale 1: Babies from Hispanic parents should be tested for sickle cell anemia.

Rationale 2: Chinese parents are more likely to avoid direct eye contact.

Rationale 3: When dealing with Hispanic families, it is important to touch the baby while complimenting the baby. Many Mexican Americans believe that it is bad luck to compliment a child without touching the child. It results in the evil eye.

Rationale 4: Native American babies are prone to developing hypothyroidism.

Global Rationale: When dealing with Hispanic families, it is important to touch the baby while complimenting the baby. Many Mexican Americans believe that it is bad luck to compliment a child without touching the child. It results in the evil eye. Babies from Hispanic parents should be tested for sickle cell anemia. Chinese parents are more likely to avoid direct eye contact. Native American babies are prone to developing hypothyroidism.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 25.4: Incorporate the physical, cognitive, and emotional development of children into comprehensive health assessment.

Question 27

Type: MCMA

The nurse has reviewed the objectives of Healthy People 2020 related to childrens health issues. As the nurse looks through a magazine, several articles seem to be related specifically to the objectives. Which of the following articles are associated with these objectives?

Standard Text: Select all that apply.

1. The three best ways to keep your children safe from guns in your home.

2. Back to sleep, baby; the importance of placing your baby on his or her back to sleep.

3. A strong marriage means strong children.

4. My daughter wouldnt stop drinking while she was pregnant; how I helped her.

5. I am a teen and I took the pledge not to text and drive.

Rationale 1: The three best ways to keep your children safe from guns in your home. Firearm safety is listed as one of the objectives of Healthy People 2020 to reduce rate of child deaths.

Rationale 2: Back to sleep, baby; the importance of placing your baby on his or her back to sleep. Education for caregivers about ways to reduce an infants risk of developing SIDS is an objective of Healthy People 2020.

Rationale 3: A strong marriage means strong children. The importance of strong marriages is not listed as an objective of Healthy People 2020.

Rationale 4: My daughter wouldnt stop drinking while she was pregnant; how I helped her. The use of alcohol while a woman is pregnant may increase the fetus or infants risk of death and is listed as an objective of Healthy People 2020.

Rationale 5: I am a teen and I took the pledge not to text and drive. The importance of safe handling of automobiles is listed as an objective of Healthy People 2020.

Global Rationale: Firearm safety is listed as one of the objectives to reduce rate of child deaths. Education for caregivers about ways to reduce an infants risk of developing SIDS is an objective of Healthy People 2020. The use of alcohol while a woman is pregnant may increase the fetus or infants risk of death. The importance of safe handling of automobiles is listed as an objective. The importance of strong marriages is not listed as an objective of Healthy People 2020.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 25.5: Discuss the objectives in Healthy People 2020 as they relate to infant and child health.

Question 28

Type: MCSA

The nurse presented an educational program for parents regarding children and adolescent health issues noted specifically in Healthy People 2020. Following the program, the nurse listened to several people talking to each other about the contents of the program. Which of the following statements made by program participants indicate that further education is required?

1. No one needs training to put in a car seat. Parents just need to buy them.

2. As parents, we have to actively watch our children to make sure they remain safe.

3. After that program, I realize that my 14 year old may need psychologic counseling for depression. I just thought he was in a blue funk, but he could actually try to commit suicide.

4. Up until now, Ive let older children swim alone without supervision. That is going to stop.

Rationale 1: Parents should be educated about the appropriate ways to place and use car seats to reduce child deaths. Car seat placement is very important and critical to prevent injury during accidents.

Rationale 2: Parents should be educated regarding the use of active supervision as a mechanism to decrease child injury risk.

Rationale 3: Parents should recognize teens that are in need of psychologic counseling to help prevent suicide.

Rationale 4: Parents should use active supervision while young people are swimming to reduce their risk of injury or death.

Global Rationale: Parents should be educated about the appropriate ways to place and use car seats to reduce child deaths. Car seat placement is very important and critical to prevent injury during accidents. Parents should be educated regarding the use of active supervision as a mechanism to decrease child injury risk. Parents should recognize teens that are in need of psychologic counseling to help prevent suicide. Parents should use active supervision while young people are swimming to reduce their risk of injury or death.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 25.5: Discuss the objectives in Healthy People 2020 as they relate to infant and child health.

Question 29

Type: MCMA

The 15 month old has been diagnosed with acute otitis media. Which of the following nursing diagnoses would be most applicable?

Standard Text: Select all that apply.

1. Acute pain

2. Hyperthermia

3. Nutrition: altered, more than body requirements

4. Risk for caregiver role strain

5. Decreased cardiac output

Rationale 1: Acute pain. Children with acute middle ear infections typically suffer from acute ear pain.

Rationale 2: Hyperthermia. They are more likely to develop a fever. Hyperthermia is an appropriate nursing diagnosis.

Rationale 3: Nutrition: altered, more than body requirements. The child with acute otitis media is usually anorexic and less likely to be receiving adequate amounts of nourishment.

Rationale 4: Risk for caregiver role strain. The childs caregivers must be assessed to determine if they are stressed. Many parents of ill children are sleep deprived because of their childs altered sleep patterns.

Rationale 5: Decreased cardiac output. If there are any alterations with the childs cardiac output, the child with a fever may have an increased cardiac output, rather than a decreased cardiac output.

Global Rationale: Children with acute middle ear infections typically suffer from acute ear pain. They are more likely to develop a fever. The childs caregivers must be assessed to determine if they are stressed. Many parents of ill children are sleep deprived because of their childs altered sleep patterns. The child is usually anorexic and less likely to be receiving adequate amounts of nourishment. If there are any alterations with the childs cardiac output, the child with a fever may have an increased cardiac output, rather than a decreased cardiac output.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 25.6: Apply critical thinking in selected simulations of pediatric physical assessment.

Question 30

Type: FIB

The child is prescribed an antibiotic for an acute middle ear infection. The child weighs 38 pounds. The antibiotic is available as 200 milligrams in 5 milliliters. The physician writes an order for the child to receive 45 milligrams per 1 kilogram of body weight each day, divided in three equal doses. Calculate the amount of medicine the child should receive per dose. Round to the tenths place.
_______ milliliters

Standard Text:

Rationale: The child weighs 38 pounds, or 17.273 kilograms. For each kilogram of body weight the child is supposed to receive 45 milligrams of medicine each day. 17.273 x 45= 777.273 milligrams of antibiotic per day. When this number is divided by 3 (doses), it is 259.091 milligrams per dose. The medicine is available as 200 milligrams in 5 milliliters. Use dimensional analysis, ratio-proportion, or formula such as: (Ordered/Available) x Quantity. The child should receive 6.477 milliliters, or when rounded to the tenths place, 6.5 milliliters of antibiotic.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 25.6: Apply critical thinking in selected simulations of pediatric physical assessment.